[Fracture sequelae type 2 of the proximal humerus-clinical results after arthroplasty]

Locked dislocations of the glenohumeral joint are rare but often painful and are associated with limited range of motion in the shoulder. In patients of advanced age, arthroplasty is increasingly indicated as a surgical treatment option. Preoperatively, the direction of dislocation, the presence and extent of a glenoid defect, and the soft tissue situation (rotator cuff status, joint capsule) should be analyzed in a differentiated manner. Based on the above factors, we recommend the subclassification of type 2 according to Boileau: posterior locked dislocation (2a), anterior locked dislocation without glenoid defect (2b), and anterior locked dislocation with glenoid defect (2c). In the case of dorsally locked dislocation, a good clinical result can be achieved by using an anatomical endoprosthesis. For ventrally locked dislocations, we recommend using an inverse total endoprosthesis with, if necessary, bony glenoid reconstruction and transfer of the pectoralis major muscle.Level of evidence: IV.

[Fracture analysis, indication for endoprosthesis and implant selection in proximal humeral fractures]

Proximal humeral fractures (PHF) are the third most common fracture in humans and the incidence is increasing. There are basically three treatment strategies: conservative, joint-preserving reconstructive or joint-replacing procedures. In addition to fracture morphology, patient-specific and surgeon-specific factors are particularly important when deciding on treatment. The experience and training of the surgeon also play a decisive role. In the case of joint-preserving treatment, the risk of osteosynthesis failure and of sequelae of the fracture must always be assessed. If conservative or reconstructive treatment methods are not promising, the joint-replacing procedure is the treatment of choice. The anatomical fracture prosthesis is only indicated, if at all, for young patients with a destroyed humeral head with a preserved rotator cuff and large fragments of the tuberosities. In advanced age, the implantation of a reverse endoprosthesis is increasingly used for dislocated, multifragmentary PHF. In both procedures, the anatomical healing of the tuberosities has a significant impact on the functional outcome.

[Simultaneous surgical treatment of the long head of the biceps tendon during operative treatment of proximal humeral fractures]

BACKGROUND

Pathologic conditions of the long biceps tendon can be found within treatment of proximal humeral fractures or as a source of pain after surgery. However, simultaneous surgical treatment at the index surgical intervention is so far not well established. The purpose of this study is to evaluate the results of a simultaneous biceps treatment during plate osteosynthesis of proximal humeral fractures.

MATERIALS AND METHODS

Twenty-seven patients were included into this study. In 14 patients (high cosmetic and functional shoulder demand) a biceps tenodesis (LHB-TD) was carried out (7 women, 7 men; ø57 years). In 13 patients (12 women, 1 man; ø72 years) a biceps tenotomy (LHB-TT) was performed. In addition to the range of motion (ROM), the Constant score and the LHB score were evaluated.

RESULTS

All 27 patients were investigated after a mean follow-up of 25 months (range: 18-32 months). The ROM did not reveal any significant differences in either group. The Constant score was significantly decreased compared to the non-affected side (CS) without differences between the groups (LBS-TT 77 ± 9 vs. LBS-TD 77 ± 14; LBS-TT (CS) 82 ± 4 vs. LBS-TD (CS) 87 ± 4). The LHB score showed excellent results for both groups without significant differences (LBS-TT 98 ± 3 vs. LBS-TD 93 ± 10). In one patient of each group, an examiner-dependent upper arm deformity was detected. No patient complained of a subjective cosmetic deformity.

CONCLUSION

The simultaneous surgical treatment of the LHB during plate osteosynthesis of proximal humeral fractures shows good clinical and cosmetic results. In a preselected patient population (cosmetic and functional demand) the kind of treatment (LHB tenotomy or LHB tenodesis) is indifferent.

[Arthroscopic fracture treatment of the shoulder joint]

In recent years, the understanding of shoulder fractures has changed due to the progress of arthroscopy. In addition to the cosmetic result, the access morbidity, particularly the integrity of the subscapularis muscle in glenoid and scapular fractures, must be mentioned as an advantage of a minimally invasive approach. Furthermore, necessary secondary interventions, e. g. hook plate removal, can be prevented or minimized by modern implants and arthroscopic techniques.However, the available data and publications are almost exclusively limited to technical notes or small case series, so statements about faster recreation or potential reduction of infection risk cannot be made. Whether addressing concomitant injuries has an effect on the clinical and functional outcome is also unclear at the present time.

Using the LHB score for assessment of LHB pathologies and LHB surgery: a prospective study

INTRODUCTION

The long head of biceps tendon (LHB) score was designed to clinically assess LHB pathologies. Purpose of this study was to prospectively assess patients with LHB pathologies preoperatively and after LHB surgery using the LHB score.

MATERIALS AND METHODS

Fifty-seven patients (29 f/28 m, Ø age 61.0 years), showing clinical signs of LHB pathologies, were prospectively included into this study. In 43 patients LHB pathologies could be confirmed intraoperatively. Among these, in 26 patients a biceps tenodesis (group I; 8 f/18 m, Ø age 61.2 years), and in 17 patients a biceps tenotomy was performed (group II; 12 f/5 m, Ø age 64.2 years). In 14 patients no intraoperative correlate concerning the biceps symptoms could be found (group III; 9 f/5m, Ø age 56.8 years). In these patients no further LHB treatment was carried out. The clinical evaluation contained the Constant score (CS) as well as the LHB score preoperatively and 2 years postoperatively.

RESULTS

The CS improved significantly in all the three groups [group I: 41.7 (20-70) to 81.3 (62-100); group II: 42.2 (18-66) to 75.3 (41-84); group III: 45.7 (22-77) to 72.9 (48-85)] (p < 0.05). Also the LHB score increased significantly in all three groups [group I: 74.3 (41-97) to 94.2 (80-100); group II: 73.4 (57-97) to 84.2 (49-100); group III: 71.1 (58-80) to 90.8 (70-100)] (p < 0.05). Compared to group II, group I showed significant better results in the total LHB score and in the cosmetic result (p < 0.05).

CONCLUSIONS

We recommend that patients with LHB pathologies are evaluated using the LHB score, since it provides LHB related information and is a proper tool to assess the clinical outcome after surgery. However, the score is not appropriate to detect LHB pathologies preoperatively.

LEVEL OF EVIDENCE

II.

[Abduction/external rotation immobilization after primary traumatic anterior shoulder dislocation: which ortheses are suitable?]

BACKGROUND

Immobilization of the shoulder in 60 ° external rotation and 30 ° abduction after primary anterior shoulder dislocation has been shown to allow anatomical reduction and potential healing of the capsule-labrum complex. The purpose of the present study was to evaluate commercially available shoulder braces concerning functionality and comfort as well as for potential problems.

METHODS

In this study ten healthy subjects (6 female, 4 male and average age 23 years) tested four braces: 1. Omo Immobil (Ottobock), 2. Quadrat (DJO Global), 3. MP Airplane Axilla (Horst Rattenhuber GmbH) and 4. ARC XR (Bledsoe Brace Systems) with respect to functionality and comfort. Each subject completed simulated activities of daily living (ADLs) and a the end of each ADL the subject evaluated comfort, difficulty of the activities and potential pain on a points scale. The position or the change of the position were controlled by digital photographs. Additionally it was checked whether the subjects could actively change the position of the brace contrary to the desired position.

RESULTS

Braces 3 and 4 were rated significantly more comfortable (p < 0.05). Even the difficulty of the activities was rated lower and in particular putting on and taking off the braces was assessed to be significantly easier in comparison to braces 1 and 2. In addition, differences of potential pain were statistically significant and pain was experienced only with braces 1 and 2. The measuring of the position showed no significant differences (p > 0.05). For braces 1 and 2 the active change of the position by subjects was significantly higher and the arm could be rotated more against the favored position (p < 0.05). Between braces 3 and 4, there were no statistical differences during the whole evaluation.

CONCLUSIONS

Ortheses where the main joint is positioned in and not in front of the axilla or which can ensure a jointless stabilization of the shoulder or which allow an improved position by an additional sling on the opposite shoulder, are most qualified for immobilization of the shoulder in an external rotation/abduction position with respect to functionality and comfort.

Influence of age on the cell biological characteristics and the stimulation potential of male human tenocyte-like cells

The incidence of rotator cuff tears and recurrent defects positively correlate with patient age. However, this observation has never been analysed at the cellular level. The present study aims to better understand this correlation by investigating cellular characteristics of rotator cuff tenocytes of different age groups. Additionally, previous studies reported on stimulating effects of Bone Morphogenetic Protein (BMP) -2 and BMP-7 on tenocytes. Thus, the second aim was to investigate, whether the stimulation potential of tenocytes demonstrates age-related differences. Tenocyte-like cells from supraspinatus tendons of young and aged patients were analysed for the following cell biological characteristics: cell density, cell growth, marker expression, collagen-I protein synthesis, stem cell phenotype, potential for multipotent differentiation and self-renewal. To analyse the stimulation potential, cells were treated with BMP-2 and BMP-7 in 2D-/3D-cultures. Measured parameters included cell activity, marker expression and collagen-I protein synthesis. An effect of age was seen for cell growth and stem cell potential but not on extracellular matrix level. Cells from both groups responded to BMP-7 by increasing cell activity, collagen-I expression and protein synthesis. BMP-2 led to smaller increases in these parameters when compared to BMP-7. In general, 3D-cultivation improved the stimulation compared to 2D-culture. The cell biological characteristics of tenocyte-like cells, considered important for successful restoration of the tendon-bone unit, were inferior in elderly donors. This may help explain higher rates of recurrent defects seen in elderly patients. Regarding the stimulation potential, on a cellular level young and aged patients may benefit from biological augmentation with BMPs.

Effects of low doses of casein hydrolysate on post-challenge glucose and insulin levels

BACKGROUND

Ingestion of high doses of casein hydrolysate stimulates insulin secretion in healthy subjects and patients with type 2 diabetes. The effects of low doses have not been studied. The aim of this study was to assess the effect of lower doses of a casein hydrolysate on the glucose and insulin responses to an oral glucose tolerance test in patients with type 2 diabetes.

METHODS

In this randomized, placebo-controlled, double-blind study, thirteen patients with type 2 diabetes (age: 58±1 years) were studied. Glucose, insulin and C-peptide responses were determined after the oral administration of 0 (control), 6 or 12 g protein hydrolysate in combination with 50 g carbohydrate.

RESULTS

Twelve grams of casein hydrolysate, but not 6g, elevated insulin levels and decreased glucose levels post-challenge. These changes over time were not large enough to also affect the total area under the curve of glucose and insulin. C-peptide levels did not change after both treatments.

CONCLUSION

Ingestion of six grams of casein hydrolysate did not affect glucose or insulin responses. Intake of 12 g of casein hydrolysate has a small positive effect on post-challenge insulin and glucose levels in patients with type 2 diabetes.

[Arthroscopic stabilization of acute acromioclavicular joint dislocation]

During the past few years arthroscopic and minimal invasive techniques for stabilization of acromioclavicular (AC) joint dislocations have gained increasing interest. Well established procedures for open surgery were modified and implemented to attain an arthroscopic level. Furthermore implants were developed which enable these reconstructive techniques to be performed arthroscopically without the disadvantages of open procedures. The short to mid-term results described so far concerning the clinical and radiological outcome of arthroscopic stabilization techniques show an at least equal outcome to those presented in open surgery.

Anemia versus disease activity as cause of fatigue in rheumatoid arthritis

BACKGROUND

Fatigue is a common complaint in rheumatoid arthritis patients and contributes to loss of quality of life.

OBJECTIVE

To study the influence of hemoglobin levels and disease activity index upon fatigue in patients with rheumatoid arthritis (RA).

METHODS

We studied 130 RA patients for DAS 28, hemoglobin levels and fatigue as measured by FACIT F.

RESULTS

No association between fatigue with hemoglobin levels was observed. A positive association with DAS-28 was found. Decomposing DAS-28, no association could be detected with sedimentation rate but a positive correlation with analogical scale for general health, number of swollen and painful joints was found.

CONCLUSION

Although a positive association of fatigue with DAS-28 is found it appears that the most important items in connection with fatigue are swollen and tender joints as well as general health status. Hemoglobin levels were not related to fatigue in our patients.

[Classification and diagnostics of unstable shoulders]

Shoulder instability includes a vast spectrum of different manifestations ranging from painful hyperlaxity to chronic locked shoulder dislocations. A correct diagnosis and classification is essential to establish an adequate treatment strategy. The correct use of different clinical tests and signs in combination with the corresponding imaging diagnostics allows an explicit classification and therefore the correct choice of treatment regimes in the majority of cases.

Social, emotional, and behavioral functioning of children with juvenile rheumatoid arthritis

OBJECTIVE

To investigate the hypothesis that children with juvenile rheumatoid arthritis (JRA) would have more social and emotional problems than case-control classmates.

METHODS

Using a case-control design, children with JRA (n = 74), ages 8-14, were compared with case-control classmates (n = 74). Peer relationships, emotional well-being, and behavior, based on peer-, teacher-, parent-, and self-report scores on common measures, were compared using analysis of variance.

RESULTS

Relative to case-control classmates, children with JRA were similar on all measures of social functioning and behavior. Mothers reported more internalizing symptoms in the child with JRA, but child self reports and father reports showed no differences. Scores on all standardized measures were in the normal range for both the JRA and the case-control groups.

CONCLUSION

Children with JRA were remarkably similar to case-control children on measures of social functioning, emotional well-being, and behavior. These findings are not supportive of disability/stress models of chronic illness in childhood and suggest considerable psychological hardiness among children with JRA.

Psychological adjustment in breast cancer: processes of emotional distress

The process of psychological adjustment to breast cancer was examined at diagnosis and at 3- and 6-month follow-ups in a sample of 80 women with Stage I-Stage IV breast cancer. At diagnosis, symptoms of anxiety/depression were predicted by low dispositional optimism, and this path was partially mediated by use of emotion-focused disengagement coping. Younger age also was predictive of anxiety/depression symptoms at time of diagnosis, and this relationship was fully mediated by magnitude of intrusive thoughts. At 3 months, changes in anxiety/depression symptoms were predicted only by intrusive thoughts. At 6 months, low dispositional optimism reemerged as a significant predictor of changes in anxiety/depression and again was partially mediated by the use of emotion-focused disengagement coping. Independent effects for problem-focused engagement and disengagement and emotion-focused engagement coping were also found at 6 months. Implications of these data for psychosocial interventions with breast cancer patients are highlighted.

Facial cleft deformities: maternal perceptions regarding causes and interventions

Maternal perceptions regarding the causes of a facial cleft deformity as well as the quality of support during medical interventions were surveyed with an open ended questionnaire. The sample consisted of 138 mothers of children up to 10 years of age attending a facial cleft deformity clinic. The responses were content analysed and thematically grouped. It was found that the subjects' views regarding the causes of facial cleft deformities changed markedly after attending counselling sessions. Ignorance about scientifically verified causal variables such as infections, medication, situational and hereditary factors decreased appreciably. The counselling sessions appeared to play an essential role in the subjects' understanding and coming to terms with their children's deformity. Their comments concerning the children's treatment in general hospitals as well as the facial cleft unit included both frustration and praise. Suggestions on enhancing support emphasised the need for accessible information, greater reassurance from medical staff at the general hospitals where delivery took place, the formation of support groups, speedy diagnosis and referral to a multiprofessional unit as well as being allowed to be with their children in hospital before and after surgical interventions. The results were discussed and tied to the available literature.

Influence of sympathetic nervous system on dexamethasone-stimulated renal tubular transport of p-aminohippurate in young rats

After simultaneous administration of dexamethasone together with 6-hydroxydopamine or adrenergic neuronal blocking agents (alpha-methyldopa, reserpine, guanethidine) the dexamethasone-stimulated increase in renal excretion of p-aminohippurate (PAH) is distinctly diminished. The same is true for dopamine. This depressive effect could be proved by measurement of transport rates of PAH in renal cortical slices in vitro. The increase in kidney weight and in the protein content of kidney tissue in dexamethasone-treated rats is lower in rats simultaneously treated with adrenergic neuronal blocking agents of 6-hydroxydopamine. Adrenoceptor agonists and antagonists (pholedrine, orciprenaline, phentolamine, propranolol) are without influence on the dexamethasone-stimulated increase in PAH transport.

Abandoning weight-loss programmes

Published scientific reports on obesity have repeatedly confirmed subjects' difficulties in maintaining weight loss. A study of unsuccessful dieters focused on a group of 50 obese subjects who had previously joined a slimming organisation, but who had dropped out. They were interviewed with emphasis on factors relating to reasons why the weight loss programmes had been abandoned. The subjects were reached through active members, who brought along unsuccessful slimmers to the group interviews. Interviews were recorded, transcribed and analysed. The results highlighted the following problem areas: motivational issues, perception of self, interpersonal/social and situational constraints, behaviour patterns, physiological concerns, and previous experience of weight loss programmes. Sample characteristics were examined with regard to relevant demographic and educational variables. Implications of the results are discussed.

Do bile acids exert a negative feedback control of cholecystokinin release?

The influence of intraduodenal bile deficiency due to chronic bile duct obstruction and acute exogenous administration of bile acids on plasma cholecystokinin (CCK) and pancreatic polypeptide (PP) was investigated. Fourteen patients with tumor-induced bile duct stenosis and five healthy volunteers were given a liquid test meal. Four of the patients had a simultaneous pancreatic duct stenosis. On another day 4 g chenodeoxycholic acid were administered concomitantly with the liquid test meal in six of the patients and all controls. Basal and meal-stimulated plasma CCK did not differ between patients and controls. A pancreatic duct stenosis, which was associated with diminished plasma PP concentrations, had no influence on plasma CCK release. Exogenous bile acids significantly reduced the postprandial CCK response in both groups. Bile-induced inhibition was significantly greater in patients than in controls (75 +/- 7% and 44 +/- 11%, respectively; p less than 0.05). It is concluded that intraduodenal bile is an important modulator of the postprandial secretory activity of the CCK cell. Although chronic intraduodenal bile acid reduction in tumor-induced biliary duct stenosis did not influence plasma CCK levels, a negative feedback control of plasma CCK by acute bile acid administration could be demonstrated.